For the fifth time since being passed, the Affordable Care Act is an election issue — only this time Democrats are the ones talking about it.

Supporters of the law have outnumbered opponents in polls since Congressional Republicans’ failed attempt to repeal and replace the law in 2017. And Democrats have found a salient issue in the law’s protections for people with pre-existing health conditions.

“For most of the history of the Affordable Care Act, it was an issue that worked for Republicans in their campaigns, and Democrats weren’t especially thrilled to talk about it,” said Charles Franklin, a professor of law and public policy at Marquette University and director of the Marquette University Law School Poll.

Fifty percent of the people surveyed want to keep the Affordable Care Act, compared with 44 percent who want it repealed.

Ninety percent said protecting coverage for pre-existing health conditions was very important or somewhat important. The percentage was the same among people who want the Affordable Care Act repealed.

Ensuring that people with health problems can get health insurance and pay the same rates as healthy people — two key provisions in the law — has become fodder for campaign ads, angry assertions and indignant responses.

“The term pre-existing conditions — which was an insurance term that appeared on the business pages — has become a deeply held, emotional issue," said Robert Blendon, a professor of health policy and political analysis at Harvard University.

It also has caused some headaches for Republicans.

Wisconsin is among the 20 states that have asked a federal court in Texas to declare the Affordable Care Act unconstitutional — and last month asked the judge at a minimum to strike down the protections for people with pre-existing health conditions.

For its part, the Trump administration has argued the law should remain in place but the protections for pre-existing conditions should be declared unconstitutional.

Wisconsin Gov. Scott Walker — who approved the state’s joining the lawsuit — has said that if that happened, he would immediately introduce legislation to cover people with pre-existing conditions, citing a bill that passed in the Assembly in the last session.

But that bill would not have required health insurers to cover prescription drugs, rendering any provision on covering pre-existing conditions meaningless for many people.

The Assembly bill also would have allowed annual and lifetime limits on benefits. The Affordable Care Act bars those limits.

Walker has not commented on what would happen to people — the vast majority of them working in low-wage jobs that don’t provide health benefits — who can afford health insurance only because of the federal subsidies available through the law.

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Governor Scott Walker said he would ask the legislature to come back for a session to address pre-existing health conditions if needed.
WisconsinEye

Leah Vukmir, the Republican candidate for U.S. Senate, also opposes the ACA but has said she supports covering people with pre-existing conditions. She hasn’t provided details on what she would support, but she has cited the state’s former Health Insurance Risk Sharing Plan of Wisconsin, known as HIRSP, as a model.

HIRSP was an option, however, only for people who could afford health insurance.

The emergence of pre-existing conditions as a campaign issue, in some ways, is not surprising.

One in four people — 27 percent — who are 18 to 64 years old have a health condition that could have led to being denied coverage in the market for health insurance sold directly to individuals and families before the Affordable Care Act, according to the Kaiser Family Foundation.

That includes an estimated 852,000 people in Wisconsin.

There also is the question of what would happen to the estimated 17 million people this year who gained health insurance through the Affordable Care Act.

“Taking coverage away from millions of people who have had it for years just seems, to a lot of people, wrong,” Blendon said. “You just can’t go back and take coverage away from people who are seeing doctors.”

Opposing the law was much easier when it was hypothetical. That was no longer true once the Republicans had control of the White House and Congress. And Franklin speculates that people began taking the prospect of repeal more seriously when that happened.

One of the paradoxes of the Republicans’ failed attempt to repeal and replace the Affordable Care Act is people learned more about what was in the complicated law.

“We saw public opinion flip,” Franklin said.

The Marquette poll is in line with the most recent Kaiser Tracking Poll. The national poll, done in late August, found that among registered voters:

50 percent had a favorable view of the Affordable Care Act, while 40 percent had an unfavorable view.

75 percent said that protections for people with pre-existing conditions was “very important” and 15 percent said it was “somewhat important.”

Republicans don't acknowledge the people who gained coverage, said Len Nichols, a professor of health policy at George Mason University. But Democrats don't acknowledge the people harmed by the law.

Millions of middle-class individuals and families who are not eligible for federal subsidies have seen their premiums soar, rendering health insurance unaffordable for many of them.

“That’s real,” said Nichols, who is the director of the Center for Health Policy Research and Ethics at George Mason.

Walker has taken steps to help the people who have been hurt by setting up a program that will help offset insurers’ high medical claims. Premiums for health insurance sold directly to individuals and families next year will be an estimated 10 percent lower than they would have been otherwise because of the program.

The state also plans to allow the sale of health plans next year that are exempt from some of the the requirements imposed by the ACA. The health plans are controversial and will affect the market. But they could benefit some people who buy health insurance on their own and don’t get federal subsidies.

The lawsuit filed by Wisconsin and others states, though, has drawn attention to the ACA's protections for people with pre-existing health conditions, particularly after the states sought an injunction striking down the provision.

“It’s a gut-level issue for voters,” said Philip Rocco, an assistant professor of political science at Marquette University. “It’s not a place you want to be at politically.”

That creates a dilemma for Republicans.

Republican voters — 78 percent in the Kaiser poll — have an unfavorable view of the ACA. The majority of them want an alternative that has less government control over health insurance and health care and that provides consumers with more choices.

“Among the Republican base that does matter,” Blendon said.

But it is not where most people are on the issue.

“The other voters are all on the other side — you can’t take the coverage away from people,” Blendon said.